When you’re considering intensive mental health, substance use, or dual diagnosis treatment for your teen, you want the best treatment available. Whether it’s an adolescent residential treatment center (RTC), partial hospitalization program (PHP), or intensive outpatient program (IOP), you’re also concerned about something else: how you’re going to pay for it.
Two questions could be at the forefront of your mind:
- How much does teen treatment cost, anyway?
- Will insurance cover it?
As far as how much treatment costs, that varies a great deal, depending on the level of care, the specific therapeutic support, and the length of treatment your teen needs. We can answer your questions about insurance, though – and that’s what this article is all about.
We’ll start from the beginning, and discuss how the entire insurance process for teen treatment works, step by step.
Step 1: You Realize Your Teen Needs Treatment
On an emotional level, this may be the most difficult part of the process. Admitting your adolescent needs mental health, substance use, or dual diagnosis treatment takes honesty and courage. They might require residential treatment for life-threatening issues, like suicidal ideation, non-suicidal self-injury, psychosis, or other acute behaviors that make it unsafe for them to live at home. If their symptoms and behaviors aren’t acute enough to warrant 24/7 support and supervision, they might need a partial hospitalization program (PHP) or an intensive outpatient program (IOP).
Whatever level of care they require, we understand that as a parent, making these decisions is hard. But they’re necessary because untreated mental health or substance use disorders rarely resolve on their own. Without treatment, they’re likely to get worse.
You’ve probably already started researching treatment centers you think may be appropriate for your teen. Perhaps you received a personal recommendation from a friend, therapist, teacher, or family member. You looked online and found a range of options for your teen. But first, you need to answer those two questions we mention above: how much it costs, and whether your insurance will cover it.
We’ll address the second question first.
Will Insurance Cover Adolescent Mental Health Treatment?
The good news is that yes, many insurance plans cover mental health and/or substance use disorder treatment.
However, the follow-up questions might be more important:
How much they will cover?
What are the limitations for the various types of treatment or the different levels of care?
How can I access the full benefits of my policy?
We can help answer those questions – which brings us to the next step in the process.
Step 2: Ask a Treatment Center to Verify Your Insurance Benefits
Because different insurance policies may provide different benefits for each level of care, the best thing to do is let the treatment center check your insurance benefits. The information they have access to – with your consent – will determine what you do next.
Every insurance company has its own set of rules that govern coverage for mental health or substance use disorder treatment. Some policies pay the full cost of residential treatment, while others pay a percentage. Your coverage also depends on whether your insurance provider is in-network or out-of-network with the specific treatment center you’re considering.
A high-quality treatment center will be able to answer all those questions for you. They’ll also work with the insurance company and your teen’s healthcare providers to verify the treatment you want for your teen is medically necessary, which is an essential part of the process that allows everything that follows – the assessment, admissions, and treatment process itself – to begin. We’ll discuss the concept of medical necessity in more detail below, in Step 4: Establishing Medical Necessity.
Why Not Do It Yourself?
You could handle all the communication with your insurance company on your own. As the policyholder, you have access to answers to all the questions we mentioned above. It’s complicated, but it’s not beyond your reach – if you’re motivated and have time. We operate under the assumption that you have other things on your mind and strongly encourage you to let the treatment center verify your benefits.
Handling all the insurance questions yourself would mean knowing the right questions and follow-up questions to ask. To do that, you would need in-depth knowledge of the insurance utilization process and a detailed understanding of all the clinical and insurance jargon involved. While it wouldn’t be impossible for you to learn all this, it would be time very time consuming.
For instance, let’s take a simple phrase like “inpatient treatment.” For one insurance company, this might mean “hospitalization” only – as in hospitalization in a psychiatric ward in a big hospital. A different insurance company, though, might consider “inpatient treatment” the same thing as “residential treatment.” You may be an hour into a phone call with an insurance company, thinking you have residential benefits for your teen, only to learn what you’ve been talking about for an hour is the former – hospitalization – and doesn’t help your teen at all with the latter – residential treatment – which is what they need.
That would be frustrating – and that’s why it’s best to let a treatment center handle this part of the process.
Dedicated Teams to Help You Navigate the Insurance Process
A high-quality treatment center will have a verification of benefits team who knows the right questions to ask and the right people to ask them to. The verification team can get you an accurate estimate of what your out-of-pocket costs will be, which is difficult if you don’t have enough information to anticipate the costs that aren’t immediately obvious. A verification team will also learn about the benefits specific to your policy. More importantly, they’ll know how to explain them in terms you understand, so you can make the most informed and responsible decision for your child.
In addition, high-quality adolescent treatment centers have dedicated Utilization Review staff who have established, long-lasting relationships with specific insurance companies, and in some cases, the specific representatives they work with frequently. You’re more likely to get access to your full range of benefits if you allow these experts to communicate with your insurance company on your behalf.
That’s why we encourage you to let the treatment center do all the legwork for you. There’s nothing to lose, you’ll get a head start on the process, and you’ll get the most out of your policy. When you contact a treatment center, ask for a “complimentary verification of benefits.” That’s the best way to get a quick, accurate estimate of how much your insurance will cover and how much you’ll have to pay.
Step 3: Choose a Treatment Center That Provides a Full Assessment
Please note: if a teen treatment center is willing to accept your teen without conducting an assessment first, that’s a red flag.
It’s important to make sure the teen treatment center you’re researching offers a thorough, detailed clinical assessment. This assessment should gather in-depth information about your teen’s symptoms and behaviors.
A comprehensive assessment serves several purposes. First, it determines whether the treatment center is the right fit for your child. For example, if they’re diagnosed with severe psychosis and the teen treatment center does not have the staff or means to treat psychosis, you need to look elsewhere. Likewise, if your teen experiences severe behavioral dysregulation and needs a comprehensive dialectical behavior therapy program, you’ll learn during the assessment whether the treatment center can meet those needs. A thorough, comprehensive clinical assessment gets to the root of your teen’s issues, helps you determine the next step, and allows you to make an informed decision about the best course of treatment for your adolescent.
The assessment also gives you and the treatment center an idea of what level of care is needed at this time. If your teen is diagnosed with depression, several levels of care may be appropriate, depending on their symptoms and treatment history. For example, if your child is suicidal and in immediate danger to themselves, they may need acute behavioral health hospitalization. If they’re safe at home but unable to function on a day-to-day basis – meaning going to school and participating in other activities isn’t possible – they might need a partial hospitalization program (PHP) or an intensive outpatient program (IOP). If they display suicidal behavior and need full-time, 24/7 monitoring with intensive counseling, they might need a residential treatment center (RTC).
A thorough clinical assessment will determine how acute your teen’s symptoms are, which will, in turn, determine which level of care is the best fit. At this point, you and the treatment center will also have a good idea of how your insurance company views medical necessity and their expectations for meeting specific criteria for the various levels of care.
Step 4: Establishing Medical Necessity
A thorough clinical assessment will also ensure that your teen meets your insurance company’s criteria for medical necessity.
What is medical necessity?
Insurance companies will only cover the costs of mental health or substance use disorder treatment if your child meets the insurance company’s standards for medical necessity for your teen at the time. It’s easy to understand why: no insurance company will want to pay for your teen to get intensive mental health treatment at an RTC, PHP, or IOP if one-on-one outpatient therapy would just work as well. This can be a frustrating part of the process, and one of the reasons it’s important to allow a high-quality treatment center help you navigate this process.
How do they determine medical necessity?
They make their determination by evaluating comprehensive, detailed documentation of your teen’s mental health history and current level of need.
That’s why it is so important to find a treatment center that will conduct a thorough pre-admission assessment of your teen, document their findings accurately, and communicate their findings clearly to the insurance company. An experienced admissions specialist will have more success in building the case for the most appropriate level of care.
Accurate, Thorough Documentation is Essential
Any admissions representative at a mental health treatment center can sit down with you or your teen, ask questions about how they’re feeling, and take notes. But not every admissions representative knows what documents you need to support every level of care, or how to record these symptoms and behaviors in a way that serves as an acceptable form of documentation for your insurance company.
Why is proper documentation so important?
The chief component of getting insurance to cover your teen’s mental health or substance abuse treatment is documentation of need. As with any medical condition, documentation is one of the most important factors in activating insurance benefits. That’s why you need to select a treatment center that will document your adolescent’s clinical diagnosis and symptoms accurately, and then build a case for the insurance company so that increases the chance of authorization for the appropriate level of care. The treatment team should also document what course of action they will take to treat your teen. They’ll outline the customized treatment plan as well as how, and for how long, they plan to provide treatment.
In short, a high-quality teen treatment center will conduct a thorough assessment and present the results to your insurance company in a way that allows them to approve their treatment recommendations for your teen.
Step 5: Your Insurance Company Authorizes Treatment
When a high-quality treatment center conducts an assessment of your teen and determines they require an RTC, PHP, or IOP, and communicates this clearly to the insurance company, insurance will begin by approving a specific number of treatment days in advance.
This is called authorization.
When you receive authorization, that means the insurance company agrees to pay the cost of your teen’s treatment in advance for a certain period of time. Depending on the clinical acuity of your teen, this could anywhere from less than a week to a month. At the end of the time pre-authorized by the insurance company, the treatment center will ask for additional days based on the clinical recommendations of the treatment team. This is called concurrent review, which we’ll discuss below. Authorization of treatment is good news – that means your teen can complete the admissions process and start getting the mental health or substance use disorder care they need.
Concurrent Review: Tracking Progress
Throughout the days or weeks that your teen received care, the treatment center is responsible for informing the insurance company, at regular intervals, on treatment progress. Here, again, documentation is paramount. The treatment center needs to illustrate and support how they implement their original treatment plan, how your teen is benefiting from treatment, and whether they still meet the criteria for their level of care outlined by your insurance company.
At high-quality treatment centers, staff will communicate regularly with your insurance company regarding any and all updates to your teen’s progress, such as any changes in symptoms, changes in behaviors, and updates to the treatment plan. Again, this is all a part of the concurrent review. When your insurance company says they’re undergoing concurrent review, that means they’re talking to your treatment center about your teen’s progress and deciding whether your teen still meets the criteria for treatment at their current level of care. After a concurrent review, the insurance company can decide one of two things: either your teen still meets criteria at their current level of care, which means the insurance company will continue paying for treatment, or that your teen no longer meets their criteria for that specific level of care.
What do you do if insurance stops covering treatment?
At some point, your insurance company may stop authorizing coverage. This can happen at any point in time, based on treatment progress and the initial criteria determined by your insurance company.
If and when they decide to stop providing coverage, or decide to deny coverage from the outset, that doesn’t mean the decision is written in stone.
If the treatment center determines the teen should still receive treatment at their current level of care and the insurance company disagrees, they may conduct a peer-to-peer review. In a peer-to-peer review – known informally as a doc-to-doc review – the medical director of the insurance company speaks to the clinical team (typically the psychiatrist) about your child’s specific case. The psychiatrist affiliated with the treatment center will explain to the insurance company why they conclude your child needs additional time at their specific level of care. They provide evidence that your adolescent still qualifies for treatment based on medical necessity. The goal of the treatment team is to advocate for your teen, and they do this by providing accurate documentation and communication of their clinical needs to the insurance company.
If the peer-to-peer review determines your teen needs more time at their current level of care, the insurance company will approve additional treatment days.
What do I do if my insurance company denies coverage from the start?
Your insurance company may, indeed, decide to deny coverage for treatment from the very beginning. They may do this for several reasons. However, the treatment center should communicate with you every step of the way about your insurance status. If you’re denied coverage for any reason, a well-established, high-quality teen treatment center will make every effort to formulate an alternate payment plan or attempt to seek a single-case agreement from the insurance company.
Why Relationships With Insurance Companies Are So Important
You, your teen, and your family will be best served by an established, reputable teen treatment center that has excellent, established, and long-standing relationships with most insurance companies. Having well-established relationships with insurance companies means treatment staff are familiar with your insurance provider’s expectations for meeting criteria for each specific level of care. This makes it more likely that you’ll receive pre-authorization for mental health or substance use disorder treatment.
That’s why selecting a high-quality treatment center isn’t just better for your child – it’s most likely better for your wallet, too. Admissions staff at high-quality teen treatment centers have a team of experts who specialize in dealing with insurance companies. This means you’ll work with an admissions team that knows how to assess your case accurately, document it professionally, and communicate with your insurance company efficiently, all of which enables your teen to receive appropriate care without you paying treatment fees out of pocket.
Why Evolve?
- We have excellent relationships with most insurance companies and have been consistently successful in receiving authorization for our clients. We work with insurance companies such as Anthem, Healthnet, Aetna, Cigna, Blue Cross/Blue Shield, CareFirst, United Healthcare/Optum, Premera, Oxford, Beacon/ValueOptions, Humana, The Holman Group, and many others.
- Our Director of aAdmissions is a licensed mental health professional. She has advanced knowledge of the insurance utilization process as well as clinical expertise in mental health symptomology. She’s a valuable asset for parents seeking to utilize insurance to pay for their teen’s mental health or substance abuse treatment.
- We offer a thorough and comprehensive clinical assessment of your teen. We’ll ask about current symptoms and behaviors, treatment history and diagnoses, medications, IEP testing, hospital records, and psychological testing. We leave no stone unturned in learning what’s going on with your child. It’s essential to choose a teen treatment center – like ours – that offers a comprehensive assessment. The more clinical information we have, the better our chances of establishing medical necessity and getting insurance to cover treatment. Many of our families are impressed at the time we take during the assessment to fully understand your teen and get to the root of their mental health, substance use, or behavioral issues. Even with everything we do to assure an appropriate admission, we can move quickly.
- We take pride in our painstakingly accurate documentation skills. Thanks to our comprehensive pre-authorization assessments and proper documentation efforts, we have been able to successfully establish medical necessity and receive insurance coverage on behalf of most of our clients. Whatever we do, we strive to be completely transparent with you every step of the way – from the minute you first get on the phone with us, through the entire insurance utilization process, all the way through your teen’s time in treatment. We’re there for you, and we’ll do everything we can to ensure your teen gets the treatment, support, and care they need.
